Saturday, July 26, 2014

Why Excision Is Recommended


What Is Excision?

Excision is the surgical removal of tissue by cutting out. It differs from ablation/laserization/burning/vaporizing which are techniques that use a heat source to destroy tissue. “Excision removes endometrial implants by cutting them away from the surrounding tissue with scissors, a very fine heat gun or a laser beam. The technique does not damage the implants, so the gynaecologist is able to send a biopsy of the excised tissue to the pathologist to confirm that it is endometriosis and not cancer or another condition. Excision allows the gynaecologist to separate the implants from the surrounding tissue, thus ensuring that the entire implant is removed and no endometrial tissue is left.”

There are many ways to remove endometriosis from the body, but excision is considered one of the most effective methods at this time. The term excision refers to using a type of cutting method to try to remove the entire endometriosis implant and leave nothing behind.

Excision can be done with a number of different tools and methods. There are mechanical tools such as scissors or a scalpel and others methods such as laser, vaporization, or electricity; all can be used to remove endometriosis implants from organs and tissues.

In many cases, the specific tool is not the key, but rather having a surgeon who is able to use a tool or tools in a skilled and expert manner to cut away existing implants. Some surgeons even use a combination of tools depending on the location of endometriosis.

Excision is important for a couple reasons. One, it leaves tissue intact so there is something to send to pathology to confirm diagnosis. Having positive proof of your diagnosis can help treatment decisions. Two, excision is less likely to leave remaining endometriosis implants that can continue to cause symptoms and problems.

Unfortunately, there are a limited number of surgeons in the United States, and even the world, with expert excision skills. Instead, many surgeons use an ablation method that burns the surface of the endometriosis implant using heat, laser, or cautery methods, which can cause more scarring and tissue damage. In addition to possible tissue damage, this method is also more likely to leave behind some of the endometriosis because it cannot reach deep implants, nor can it be used on all organs and tissues. Plus, ablating the implants leaves no tissue for pathology to confirm diagnosis.

Finding an endometriosis specialist who has the ability to excise your endometriosis could offer you the most optimal treatment option. It can take some time and effort to find this type of surgeon, but it can be well worth it!”

Why Excision Is Preferable to Ablation?

“Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.

Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease, since the "evidence" presented in a medical journal becomes a matter of opinion rather than a matter of fact.

No long term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.”

Coagulation destroys implants by burning them with a fine heat gun or vaporising them with a laser beam. When coagulating implants, care must be taken to ensure that the entire implant is destroyed, so it cannot regrow.  Care must also be taken to ensure that only the implant is destroyed, and no underlying tissue, such as the bowel, bladder or ureter, is damaged. The possibility of accidentally damaging the underlying tissue means that most gynaecologists are wary of using coagulation on implants that lie over vital organs, such as the bowel and large blood vessels.

Of the two techniques, excision is more effective, requires more skill, and is more time consuming.

The skill and time required means that it is not used by all gynaecologists. If your gynaecologist does not have the skill to excise all your endometriotic implants, ask to be referred to a gynaecologist who specialises in endometriosis surgery and is skilled in excision.

The effectiveness of excising endometriotic implants has been shown in two clinical trials. Women who had their implants excised had fewer symptoms 12 months [6] and 18 months [7, 8] after surgery compared with women who underwent a laparoscopy without excision of their implants.”

The European Society for Human Reproductive Endocrinology guidelines encourage excision, stating that pain due to endometriosis can be reduced by surgical removal of the entire lesion in severe and in deep, infiltrating endometriosis. The guidelines also state that the best approach is to diagnose and remove endometriosis surgically. Despite these recommendations, most surgeons do not excise endometriosis during diagnostic procedures. A recent survey of British gynecologic consultants and surgeons found that only 30% performed surgical removal. In the survey, 95% favored ablative techniques, and 25% used both ablation and excision.7 This reluctance to adopt excision of endometriosis has been judged appropriate by some, due to the lack of good long-term data regarding its effects and the increased potential for surgical complications.


A review of the literature yields 2 randomized controlled trials (RCTs) and 5 cohort studies addressing the effectiveness of laparoscopic excision for the treatment of endometriosis.8-14

A 2003 study involving 39 subjects with histologically confirmed endometriosis randomized

patients to either immediate excisional surgery or diagnostic surgery only.8 All patients underwent second-look laparoscopy, with 80% of women in the excision group reporting improvements in pain symptoms versus 32% in the control group. Women with more advanced disease experienced a greater response to laparoscopic excision. Furthermore, responses on quality-of-life instruments showed significant improvements in both mental and physical scores.8 In the second RCT, 24 women with mild endometriosis (stage 1 or 2) were randomized to either laparoscopic excision or ablation of endometriotic lesions.9 There was no significant difference between groups with respect to pain relief and pelvic tenderness, but there was a significant improvement in the signs of endometriosis (eg, back pain, fatigue, tenderness, adnexal pain) in the excision group. As in the first RCT, severity of symptoms was the strongest indicator of the success of treatment.8,9 The latter study identified no additional morbidity associated with excision, but both trials were limited by small size and short follow-up.8,9


There were 5 cohort studies involving laparoscopic excision of endometriosis, 4 of which directly assessed the effects of excisional surgery on pelvic pain (Table).11,12,14-16 A 1996

investigation reported on a 2-year follow-up of women undergoing excision versus laser

vaporization. At 12 months, 96% of excision patients and 69% of vaporization patients were pain-free, falling to 69% and 23%, respectively, at 24 months.10 Findings from a study of 135 patients with a mean follow-up of 3.2 years revealed reductions in pain scores related to dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia.11 As expressed by survival curves, the likelihood of avoiding further surgery over the subsequent 5 years was 64%, with the strongest predictive factor for reoperation being a revised American Fertility Score of 70 or higher. Interestingly, endometriosis was not identified at the time of subsequent surgery in 32% of subjects.11 A study that followed 62 women for an average of 13 months reported a 71% satisfaction rate with excision, but 40% of subjects still required regular medication and 11%

underwent further surgery.12 Finally, among 107 women treated by laparoscopic excision and followed for a mean of 7.65 years, the 2-, 5-, and 7-year surgery-free rates were 79.2%, 51%, and 41.4%, respectively.14 All of these studies were limited by the lack of a control group, but they consistently showed a 2-year surgery-free rate of more than 70%. Three studies presented data regarding quality of life before and after excision.11,12,17 A 4-month follow-up of 57 consecutive patients undergoing laparoscopic excision of endometriosis reported significant improvement in the physical components of quality-of-life scores, but showed no improvement in the mental components.17 The aforementioned study of 135 patients noted improvement in a quality-of-life scale that persisted through 5 years of follow-up, but these improvements did not reach the quality of life of healthy subjects. 17 Finally, the study that involved 62 patients noted only limited increases in quality-of-life scores, with improvement in social life reported by 32%, in relationships by 24%, and in anxiety levels by 39%.12


Deep dyspareunia is a common complaint among women with endometriosis, affecting 60% to 79% of patients undergoing surgery.13 An observational prospective cohort study addressed the effects of laparoscopic excision on deep dyspareunia and overall sexual function. The study enrolled 68 women, of whom 87% had stage 3 or 4 disease. At 6 and 12 months’ follow-up, patients demonstrated both significant reductions in the intensity of deep dyspareunia and

improvements in the quality of sexual function.13 Two of these studies reported significant improvements in pleasure and comfort.11,13 One RCT comparing laparoscopic endometriosis ablation with diagnostic laparoscopy reported a 62.5% improvement in symptoms at 6 months versus 22% in the control group.15 At a mean followup of 73 months, there was a symptom recurrence rate of 74%, but a 55% rate of satisfactory symptom relief. Whereas the cohort study of 107 patients noted a 2-year reoperation rate of 21.2%, this RCT yielded a median time to symptom recurrence of 19.7 months and a 2-year reoperation of 37%.14,16 Overall, these data have several limitations.


All of the studies were conducted by expert laparoscopic surgeons, whose results are unlikely to be reproduced by the generalist surgeon. Also, the absence of a control group in the cohort studies limits the significance of their findings. Finally, variations in designs, endpoints, and surgical techniques make it difficult to generalize. There is no definitive study as of yet, and a large, well-designed RCT of laparoscopic excision versus ablation of endometriosis remains to be performed. Based on the studies performed to date, it is the author’s opinion that laparoscopic

excision of endometriosis, when technically feasible, should be the standard of care. First, whereas visual diagnosis of endometriosis is correct in only 57% to 72% of cases, excisional

surgery yields specimens for histologic confirmation—and identifies endometriosis in 25% of “atypical” pelvic lesions as well.18 The availability of such specimens would prevent unnecessary treatment and ensure more reproducible research findings. Excision should also reduce the incidence of persistent disease secondary to inadequate “tip of the iceberg” destruction, removing both invasive and microscopic endometriosis to provide the best possible symptom relief.


Finally, the results of excision are comparable to or better than those of ablation. Endometriosis usually recurs, but excision both prolongs the time to reoperation and reduces the severity at second surgery. Excision provides the greatest benefit for patients with extensive disease without increasing complication rates or morbidity Surgical treatment of endometriosis can be difficult due to its tendency to target the uterosacral ligaments adjacent to the ureter and to cause fibrosis and adhesions. However, these complexities need not result in suboptimal debulking of lesions. These studies suggest that converting from ablative to excisional therapy will refine diagnosis,

reduce disease burden and morbidity, lengthen the time to recurrence, and improve outcomes overall..”

Studies on Excision of Endometriosis:

The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient include substantial symptom relief and resolution of infertility in many cases, circumvention of major abdominal surgery with its related morbidity, and avoidance of the hypoestrogenic effects of ovarian suppression therapy, which prohibits fertility during its administration and never eradicates deep infiltrating endometriosis. The laparoscopic approach can be lengthy, and the persistent nature of the disease may dictate more than one application. Therefore, determining factors in achieving the desired outcome are the surgeon's skill and tenacity and the patient's persistence.”

Complete laparoscopic excision of endometriosis in teenagers--including areas of typical and atypical endometriosis--has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.” “A recent article published by Dr. Yeung in Fertility & Sterility 2011:  (1) demonstrates that complete excision (even in teenagers) by an expert is potentially curative, and can eradicate disease; (2) implies the importance of early excision, to prevent progression and preserve fertility, and (3) indicates that these results do not require long-term hormonal suppression.”

Results: There was a reduction in all pain scores over the five year follow up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was seen in the excision group at 5 years (univariate p= .031 and multivariate p=.007). More women went on to use medical treatments for endometriosis amongst the ablation group (p= .004) by 5 years.

Conclusions: Surgical treatment of endometriosis provides symptom reduction for up to 5 years. There are some limited areas, such as deep dyspareunia, where excision is more effective than ablation.”


"CONCLUSIONS: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life for up to 5 years. The probability of requiring further surgery is 36%. Return of pain following laparoscopic excision is not always associated with clinical evidence of recurrence."

Surgical treatment of endometriosis leads to endothelial function improvement, resulting in reduction of cardiovascular risk.”

"A new study shows women who undergo surgical treatment for endometriosis have a lower risk of developing ovarian cancer. The Swedish research also found that hormonal treatments for endometriosis did not lower the risk."

Diagrams detailing appearance, anatomic site, and surgeon's suspicion of endometriosis versus atypical lesions were compared with final histologic diagnosis. The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis.These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis."

"Endometriosis could still be regarded as a recurrent disease; nevertheless recurrence could not be ascribed to the retrograde menstruation, but to an incomplete surgical intervention, since it is demonstrated that endometriosis lesions could be also made up of microscopic foci (Redwine, 2003), and or to different timing of growth of the lesions in the same patient, probably due to individual susceptibility that is a typical phenomenon of the diseases inducted by endocrine
disruptors (Mori et al., 2003). Therefore surgery, if complete in exhausted growth disease can be considered curative. Contrarily, exposition to endocrine disruptors such as synthetic estrogens or SERM chemical compounds, though reducing the symptoms, could increase the growth of

"A systematic review found that post-surgical hormonal treatment of endometriosis compared with surgery alone has no benefit for the outcomes of pain or pregnancy rates, but a significant improvement in disease recurrence in terms of decrease in rAFS score (mean = −2.30; 95% CI = −4.02 to −0.58) (Yap et al., 2004). Overall, however, it found that there is insufficient evidence to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified (Yap et al., 2004)....Moreover, even if post-operation medication proves to be effective in reducing recurrence risk, it is questionable that ‘all’ patients would require such medication in order to reduce the risk of recurrence. It has been reported that about 9% of women with endometriosis simply do not respond to progestin treatment (Vercellini et al., 1997), which may result from progesterone receptor isoform B (PR-B) down-regulation (Attia et al., 2000). If PR-B is silenced due to promoter methylation, as reported in endometriosis (Wu et al., 2006b), progestin treatment or OC use may be of little value since the action of progestins is mediated mostly through PR-B. Therefore, the use of post-operation medication indiscriminately may cause unnecessary side effects (and an increase in health care costs) in some patients who may intrinsically have a much lower risk than others and in others who may be simply resistant to the therapy. The identification of high-risk patients who may benefit the most from drug intervention would remain a challenge. Finally, whether a single medication represents the optimal interventional option is debatable. The recent finding that PR-B and nuclear factor-κB (NF-κB) immunoreactivity jointly constitute a biomarker for recurrence (Shen et al., 2008) suggests the possibility that perhaps a combination of drugs may be superior to a single drug in reducing the risk of recurrence, especially if PR-B is silenced due to promoter methylation."

"Several clinical studies suggest that the recurring endometriotic lesions arise from residual lesions or cells not completely removed during the primary surgery. Nisolle-Pochet et al. (1988) reported that in women who received microsurgical resection of ovarian endometriosis, a high prevalence of active endometriosis without signs of degeneration is found after hormonal therapy. Compared with women receiving no treatment, the mitotic index was similar in women treated for 6 months either with lynestrenol (a progestin), gestrinone (an androgenic, antiestrogenic and antiprogestogenic agent) or buserelin (a GnRH agonist) (Nisolle-Pochet et al., 1988). This suggests that hormonal treatment does not lead to a complete suppression of endometriotic foci and that recurring lesions appear to grow from the residual loci. Vignali et al. (2005) found that for those patients who underwent a second surgery, the recurrence of deep endometriosis is observed in the ‘same’ area of the pelvis involved in the first operation. Exacoustos et al. (2006) reported that of 62 patients with recurrent endometriomas, 50 (80.6%) had recurrence on the treated ovary, 7 (11.3%) on the contralateral untreated ovary and 5 (8.1%) on both the treated and untreated ovaries. Overall, the majority of recurrent cases (88.7%) have recurrence involving the treated ovary, suggesting that the recurring cysts seem to grow likely from the residual loci."

"Above all, this report is directly at odds with the one reporting that recurrent symptoms still occur in about 10% of women even ‘after’ hysterectomy and bilateral salphingo-oophorectomy are performed (Namnoum et al., 1995). In fact, some earlier reports also found recurrence after hysterectomy. Sheets and Fetzer (1956) and Andrews and Larsen (1974) reported a 1–3% reoperation rate after hysterectomy with some ovarian conservation. Hammond et al. (1976) reported an 85% reoperation rate 1–5 years after hysterectomy surgery with ovarian conservation. Some anecdotal reports also documented the development of endometriosis after hysterectomy (Goumenou et al., 2003)."

"RESULTS: Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year.

CONCLUSION: Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease."

"Main outcome measures Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications.

Results Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0.595:0.729, P= 0.002) and EQ thermometer (68.9:77.7, P= 0.008); SF12 physical score (44.8:51.9, P= 0.015); sexual activity (habit P= 0.002, pleasure P= 0.002 and discomfort P≤ 0.001). Only the mental health score of SF12 failed to show any statistical improvement (47 1:48.4, P= 0.84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8.0:4.0, P≤ 0.001), pelvic pain (median 7.0:2.0, P≤ 0.001), dyspareunia (median 6.0:0.0, P≤ 0.001) and rectal pain scores (median 4.0:0.0, P≤ 0.001). Complications were noted, but were deemed to be acceptable for the extent of the surgery.

Conclusions This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial."

"Recent findings: Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometrioma are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex.

Summary: Laparoscopic excision is currently the ‘gold standard’ approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies."

"Surgical excision can be carried out by laparoscopy, laparotomy or vaginally using sharp dissection, electrosurgery or with the use of a CO2 laser. Excision is the treatment of choice because of a high pregnancy rate, a complete cure of pain in most women, and a low recurrence rate....The choice of treatment will therefore depend on the local expertise with minimal invasive surgery, certainly if a first excision has been incomplete and pain symptoms recur."

Which one is better for pelvic pain and recurrence in ovarian endometrioma, excisional surgery versus ablative surgery? recent Cochrane review

A recent Cochrane review evaluated the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage followed by electrocoagulation of the cyst wall, measuring the primary outcome as pain symptom improvement [15]. Two randomized studies of the laparoscopic management of ovarian endometrioma, greater than 3 cm were included. Laparoscopic excision of the cyst wall of the endometrioma was associated

with a reduced recurrence rate of dysmenorrhea (OR, 0.15; 95% CI, 0.06 to 0.38), dyspareunia (OR, 0.08; 95% CI, 0.01 to 0.51) and nonmenstrual pelvic pain (OR, 0.10; 95% CI, 0.02 to 0.56). For the secondary outcome measures, laparoscopic excision of the cyst wall was associated

with a reduced rate of recurrence of the endometrioma (OR, 0.41; 95% CI, 0.18 to 0.93) and with a reduced requirement for further surgery (OR, 0.21; 95% CI, 0.05 to 0.79) compared with ablative surgery.”


A particular strength of this study is that it describes outcomes after excision for endometriosis from multiple referral centers; as such, it is the first study known to include data from multiple centers after excision. This shows that a multicenter trial is feasible, even among surgical referral sites. Most studies that have been published on excision for the surgical management of endometriosis have been from a single surgeon or center.5,8,9 Patients were suspected to have endometriosis based on the overall assessment of the surgeon from the clinical history and examination findings. One of the benefits of excision is the histologic confirmation of disease, and more than 7 of 10 patients who underwent surgery in thisstudy for the suspicion of endometriosis had histologically proven disease. Even more noteworthy is that of the patients in whom histologically proven endometriosis wasvfound, a high percentage (84.6%) had received either previous hormonal therapy or surgery by ablation as “treatment” for presumed endometriosis, indicating that these interventions are ineffective at suppressing or preventing

disease. The data from this study further indicate that the addition of hormonal suppression after excision did not further reduce VAS scores for pain or benefit QOL scores, when compared with patients without postoperative hormonal suppression.


In the RCT of excision versus ablation for endometriosis by Healey et al.5 (2010), differences in pelvic pain were not statistically significant, but there were trends for a difference in bowel-related symptoms and dyspareunia. In addition, as mentioned earlier, the results of their study came from a single center and are likely only applicable to generalist gynecologists. In our prospective multicenter study on excision for endometriosis, there were significant reductions in pelvic pain, dysmenorrhea, dyspareunia, and bladder symptoms but not bowel symptoms.

In contrast to the study by Healey et al.,5 where fewer than one-third of patients who underwent surgery previously received either hormonal or surgical treatment, patients in our study received either hormonal or surgical treatment in the vast majority of cases (_80%). One might predict

that patients having previous treatment might respond with less benefit from another surgical intervention, yet the rates of improvement in VAS scores were comparable in both studies. Also of note is the finding that patients did not have symptom improvement in QOL scores when no

endometriosis was found histologically. A strength of this study is the inclusion of a single validated measure of QOL before and after excision surgery. A scale of 0 to 100 for the QOL score is easy to use and has been validated as an assessment tool.7 Most studies on the surgical management of endometriosis use pelvic pain as the primary outcome as measured by VAS scores.1,3,5 A potential problem with using pelvic pain as the primary outcome of a study on endometriosis is that some components of pain may improve after surgically treating endometriosis whereas others may not, at least to the same extent. A QOL assessment may be a better overall measure of the clinical benefit of surgery for treating endometriosis by translating multiple pain symptoms to a single measure of their effect on daily functioning. In fact, published reviews have recommended the inclusion of a QOL assessment in trials that look at pain as an outcome.10,11 Our study showed a statistically significant improvement in QOL scores after excision at multiple centers. It is our recommendation that a QOL measure be

used as the primary symptom outcome measure for future comparative trials on excision versus ablation in the surgical management of endometriosis. This study has produced an estimate of the benefit on QOL after excision to be an increase of 20 points. There are no known studies

that have evaluated QOL after ablation. Weaknesses of this study include the skewed actual numbers of recruitment, with more than 58 of 100 patients coming from a single center and 78 of 100 from 2 centers. Perhaps more important is the lack of quality assurance or some objective way to determine whether adequate or complete excision of all areas of abnormal

peritoneum was achieved at each of the centers. In any subsequent randomized comparative trial comparing excision and ablation, objective or third-party quality assurance will need to be included for both techniques, especially if a particular referral center favors a particular approach over the other. As reported in a recent study on complete excision of endometriosis in teenagers, one of the most important benefits of excision may not be symptom relief but may be eradication of disease.12 Potential eradication of disease by excision might benefit future fertility, and this

benefit might need to be evaluated also in a comparative trial of excision versus ablation in the treatment of endometriosis.


One of the aims of this study was to obtain an estimate of the rate of patients presenting to referral centers for pelvic pain or endometriosis (in particular, centers that specialize in the excision of endometriosis) who would be willing to be randomized to either excision or ablation of endometriosis at the time of surgery. The vast majority of patients (84.0%) were willing to be randomized when asked this question. This bodes well for the feasibility of a randomized comparative trial even at referral centers that specialize in a particular surgical approach to the treatment of endometriosis.


The results of this study indicate that patients were overwhelmingly willing to be randomized to either excision or ablation for endometriosis even at referral centers, that QOL may be a better overall measure as a primary outcome when one is looking at the benefit of surgery for endometriosis, and that a comparative RCT is feasible, as well as needed, among multiple centers that specialize in surgically treating endometriosis.”


Laparoscopic surgical removal of endometriosis (through either excision or ablation of endometriosis or both) is an effective first-line approach for treating pain related to endometriosis (Jacobson et al., 2009). Although RCTs have failed to demonstrate the benefit of excision over ablation (Wright et al., 2005; Healey et al., 2010), there is unanimous consensus over the recommendation to excise lesions where possible, especially deep endometriotic lesions, which is felt by most surgeons to give a more thorough removal of disease (Koninckx et al., 2012). It is also acknowledged that, even after expert removal of endometriosis, there may be a recurrence rate of symptoms and endometriotic lesions that varies from 10 to 55% within 12 months (Vercellini et al., 2009), with recurrence affecting _10% of the remaining women each additional year (Guo, 2009). The risk of requirement for repeat surgery is higher in women

younger than 30 years at the time of surgery (Shakiba et al., 2008). First operations tend to produce a better response than subsequent surgical procedures, with pain improvements at 6 months in the region of 83% for first excisional procedures versus 53% for second procedures (Abbott et al., 2004). Excessive numbers of repeat laparoscopic procedures should therefore be avoided. The role of a purely diagnostic laparoscopy has been questioned and, ideally, there

should always be the option of continuing to surgical removal of endometriosis, within the limitations of the surgeon’s expertise….Laparoscopic surgical removal of endometriosis is recognized as being effective in improving fertility in stage I and II endometriosis (Jacobson et al., 2010)… Laparoscopic excision (cystectomy) whenever possible for endometriomas

.4 cm in diameter improves fertility more than ablation (drainage and coagulation) (Hart et al., 2008).”

What Some Of The Experts Have To Say:
Can endometriosis be eradicated?

For the most optimal results, in our opinion, excision of all visible disease must be achieved, which depends on two important factors:

1.     identifying all forms of the disease – including both its typical and atypical or subtle forms [16], and

2.     completely removing the disease wherever it is found (excision).


We published a study [17] recently, which is the largest prospective study of excision in teenagers.

The majority of the women had received previous hormonal treatments, previous (sometimes multiple) surgeries by ablation, and had an “awful” or “poor” quality of life.

All the teenagers received “complete excision” (defined as above) by an expert and experienced surgeon. They were followed for up to 5 years, the mean interval being 2 years. Overall the pain scores and quality of life (perhaps more importantly) improved significantly. The rate of recurrent or persistent endometriosis on second-look laparoscopy was zero.

This data indicates that complete excision is an important part of the management plan for pain. More importantly perhaps, is the implication that there is a potential for complete eradication of disease.

-- Co-author Assistant Professor Patrick Yeung Jr, Saint Louis University

The potential benefit of early diagnosis and complete excision


The data discussed above indicates that early diagnosis and complete excision is the best way to improve quality of life, and perhaps to prevent progression of endometriosis and thereby benefit long-term fertility.

However, further systematic, multi-centre and longer-term studies are needed to confirm this hypothesis.

---Co-author Dr Robert Albee Jr, Center for Endometriosis Care

Embracing the challenge of complete excision surgery, the gold standard of endometriosis treatment

If you are a gynecologist dealing with endometriosis, you know the trite drill dictated by conventional wisdom: in the office diagnose pelvic pain as a sexually transmitted pelvic inflammatory disease (PID) and treat with antibiotics; diagnose recurrent pelvic pain as recurrent PID in a woman with loose morals and treat again with antibiotics; when the patient (sometimes virginal) re-presents with pain thought to be due to yet another recurrent sexually transmitted disease, perform a laparoscopy and finally diagnose endometriosis; shine a coherent beam of light at the disease or put a metal electrode on the various spots and step on a foot pedal to unleash unseen electrons and pronounce that the disease is treated; after surgery administer powerful and expensive medical agents with multiple side-effects and reassure the patient that this combination of treatment will be the best treatment for her disease since this is what most clinicians use; shuffle the suffering patient to various other practitioners, including psychiatrists and pain clinics; question her about childhood sexual abuse when her pain does not respond well; repeat a laparoscopy; repeat the same therapies which did not seem to work the first time; repeat these a third time to be certain they did not work the second time; perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy; rush off to perform a routine vaginal delivery when the patient returns to the office complaining of pain and vasomotor menopausal symptoms. What is wrong with this picture? Modern therapy of endometriosis has become unimaginative, rigid and dogmatic.

It is universally acknowledged that endometriosis is a confusing, enigmatic, mysterious disease, but this need not be so. Confusion is an opportunity for change if this confusion is recognized for what it is: lack of accurate information. Whereas the debate about the origin of the disease rages confusingly, the debate on treatment has become quite distilled. The word 'treatment' is used here in the same manner as when one talks about treatment of a urinary tract infection: the disease is gone when treatment is concluded, and symptoms once caused by the disease are gone as well. This use of the word 'treatment' is familiar and comforting to patients and physicians and can be used to summarize modern therapy of endometriosis accurately in one sentence - Since no available medicine eradicates endometriosis, surgery is its only treatment. It thus becomes a question simply of which type of surgical treatment most effectively eradicates the disease.

Most of the confusion regarding endometriosis stems from long-held biases that are rooted in misinformation. Our profession must grapple with the probability that Sampson's theory of origin is incorrect because the facts upon which it was based were incorrect. Sampson did not have all the facts we have today when he devised this theory. It seems unlikely that he would have supported reflux menstruation as the origin of endometriosis if he had been aware of the information that we now possess. Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Misunderstanding about endometriosis is due to a predictable phenomenon which has a name: Berkson's fallacy. This fallacy has operated from the very beginning of our understanding of the disease. Because Berkson's fallacy has operated unidentified and uncorrected for many decades, its deleterious effects on our understanding have been magnified over time and have become huge. This has led to enormous inertia in understanding, treatment and research because we have been unwilling to give up the past, partly because of the fear that we have been so wrong for so long. Things can be made right by leaving our minds open to new thoughts regarding the disease, with the possibility that we must reject much of what we think we know. Understanding clearly the origins of our current confusion will make it easier to face a future which contains the real truth about the disease.

The practice of medicine is sublimely simple because there are only three choices available for almost any ailment: (1) Do nothing. (2) Treat with medicine. (3) Treat with surgery. The patient with endometriosis will already have tried doing nothing, and that did not work because she is now in your office. This simplifies greatly the care of patients with endometriosis, because once the diagnosis is made surgically, there are only two treatment options: medicine or surgery. (Observation of a treatable disease which has led to surgery is not rational by anyone's judgment. If observation seems rational, then surgery should not have been done.) To decide between these two modalities, more information is needed, which you will find here among the pages of this site. It should be apparent after reading through the various articles that endometriosis is a disease which requires surgery for diagnosis and treatment, and this should be a part of the process of informed consent with the patient.

So... how does one treat virtually any manifestation of endometriosis surgically? Since surgery is a visual as well as a tactile and judgmental art, an effort has been made on this site to provide illustrations of surgical strategies with the hope that if a surgeon sees what is supposed to happen, it can be made to happen in that surgeon's hands. The articles on surgical treatment admittedly place a heavy emphasis on excision, which alone is able to treat both superficial and invasive endometriosis completely anywhere in the surgery to be done in gynecology, and some cases will seem to be the most difficult surgery possible anywhere in the human body, maximally taxing the mental and physical strength of the surgeon. For those surgeons who relish challenge, endometriosis is the perfect disease.”

When a patient has deeply invasive endometriosis of the posterior cul de sac or rectovaginal septum, or encapsulated ovaries fixed to the pelvic sidewall by adhesions and possibly retroperitoneal, a tension arises in the young patient who definitely has her childbearing years in front of her. How do we best treat this woman’s pain while preserving as best we can her right to make decisions about future pregnancies?

Many gynecologists are critical of the meticulous excision of endometriosis deep into the rectovaginal septum and pelvic sidewall because they think it will result in a flood of pelvic adhesions. If adhesions do occur, they again believe the relative risk of infertility will increase. Fearing that endometriosis will return no matter what they do, they aren’t likely to support a meticulous pelvic dissection as the best form of treatment. Their approach would be to leave the deep disease untreated and prescribe suppressive medication. They would encourage pregnancy as soon as it becomes feasible for the individuals involved.

I favor excision of deep endometriosis even in the young patient for the following reasons:

Limited surgery followed by medical suppression means the patient undergoes both surgery and the medication treatment. Side effects of the medication are considerable, sometimes incapacitating, and frequently quite expensive. Additionally the patient must still deal with any residual symptoms of the endometriosis left behind. Many times the "limited surgery" results in skimming the top off the area of deep disease, leaving behind the remainder. This allows subsequent adhesion formation to bury deep disease. Deep disease covered by new adhesions actually increases the pain, leaving a very dissatisfied patient.

In contrast, with lapex (laparoscopic excision), all endometriosis is removed. Any adhesions that may form will do so immediately post op, because no disease has been left behind to create new ones on an ongoing basis. Our follow-up surveys dating back to 1991 for hundreds of women demonstrate a recurrence rate of only 10-15%. More than 85 of every 100 women will have no more endometriosis. Of the remaining patients, those who do have endometriosis generally have one or two small foci that were not removed at surgery. This can be by accident or design (as in the case of a woman with very limited tubal endometriosis, where it is felt that deep excision could lead to scarring contraindicated in a woman trying to conceive. Such cases are very infrequent).

Adhesions that result from conservative aggressive lapex actually vary greatly from patient to patient. In my experience patients have as much risk of adhesion formation from the progression of disease that persists or that was untreated as from excisional surgery. If the ultimate risk of adhesions is the same in both cases, why not relieve the pain by getting rid of the disease?

The sooner in a woman’s life the disease can be eradicated, the better her long-term outlook becomes. Drug therapy that can destroy endometriosis has yet to be discovered. The best such drugs can do is (sometimes) suppress endometriosis. So a woman who uses such medications keeps herself at risk that the effects of her endometriosis will worsen.

I believe that the best treatment for young women in this situation is for a surgeon with a great deal of experience with endometriosis to perform aggressive conservative surgery. The surgeon should use the most appropriate surgical techniques to minimize adhesion formation (see Adhesions). As for possible future pregnancies, I always feel that a woman who gets herself healthy first will be in a much better position to be the best possible mother to her child. And, although it is true that some cases of infertility can be traced to endometriosis, most women with endometriosis who want to have babies, have babies. The automatic assumption that a woman with endometriosis will have difficulty conceiving is simply not true. Each case should be evaluated individually, and each woman’s goals, feelings, and attitudes carefully considered.”

But excisionists like Yeung who train at the Center for Endometriosis Care in Atlanta don't accept that. They're taught to recognize subtle forms of the disease, including the slightest of spots, which other OB-GYNs either miss or dismiss as something else. Then they use a CO2 laser to cut out every last bit of it.Most OB-GYNs only cauterize or ablate tissue on the surface of organs.”
"Although excisional biopsy and resection offers a higher success rate in treating the disease, surgical excision also requires a higher level of surgical skill. As a result, many patients receive incomplete treatment, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that many women who have undergone repeated surgeries and had a hysterectomy still suffer.86 The need to improve surgical approach and/or engage in timely referrals is unquestionable.
...Complete excision of endometriosis, including vaginal resection, offers a significant improvement in sexual functioning, quality of life, and pelvic pain, including in those symptomatic patients with deeply infiltrating endometriotic nodules in the posterior fornix of the vagina.94 As well, the technique offers good results in terms of reduced bladder morbidity and bowel symptoms.95,96,97 However, in that this kind of surgery requires advanced skills and anatomical knowledge, again, it should be performed only in selected reference centers.95 "

Other Sources on Excision: